Anastomotic Recurrence of Colon Cancer-is it a Local Recurrence, a Second Primary, or a Metastatic Disease (Local Manifestation of Systemic Disease)?

Implantation metastasis from sigmoid colon cancer to rectal anastomosis proved by whole exome sequencing and lineage inference for cancer heterogeneity and evolution analysis: Case report and literature review

It was estimated that 70% of patients with colorectal cancer were found to have viable exfoliated malignant cells in adjacent intestinal lumen. Exfoliated malignant cells had been reported to implant on raw surfaces, such as polypectomy site, anal fissure, anal fistula, hemorrhoidectomy wound, and anastomotic suture line. Tumors at anastomosis could be classified into four groups: local recurrence, local manifestation of widespread metastasis, metachronous carcinogenesis, and implantation metastasis. However, all of the previous studies only reported the phenomena of implantation metastasis at anastomosis. No study had proved the origin of anastomotic metastasis by genomic analysis. In this study, a 43-year-old woman presented with persistent hematochezia was diagnosed as having severe mixed hemorrhoids. She was treated by procedure for prolapse and hemorrhoids (PPH), without receiving preoperative colonoscopy. Two months later, she was found to have sigmoid colon cancer by colonoscopy due to continuous hematochezia and received radical sigmoidectomy. Postoperative histological examination confirmed the lesion to be a moderately differentiated adenocarcinoma (pT3N1M0). Six months later, she presented with hematochezia again and colonoscopy revealed two tumors at the rectal anastomosis of PPH. Both tumors were confirmed to be moderately differentiated adenocarcinoma without lymph node and distant metastasis and were finally removed by transanal endoscopic microsurgery (TEM). Pathological examination, whole exome sequencing (WES), and Lineage Inference for Cancer Heterogeneity and Evolution (LICHeE) analysis demonstrated that the two tumors at the rectal anastomosis were probably implantation metastases arising from the previous sigmoid colon cancer. This is the first study to prove implantation metastasis from colon cancer to a distal anastomosis by WES and LICHeE analysis. Therefore, it is recommended to rule out colorectal cancer in proximal large bowel before performing surgery with a rectal anastomosis, such as PPH and anterior resection. For patients with a suspected implanted tumor, WES and LICHeE could be used to differentiate implantation metastasis from metachronous carcinogenesis.

Unexplained neoplastic anastomotic recurrence after right hemicolectomy: a case report

Background

Anastomotic recurrences of the colon are postulated to arise due to inadequate margins, tumor implantation by exfoliated cells, altered biological properties of bowel anastomosis, and missed synchronous lesions. In this paper, a case of unexpected early local recurrence after surgery for colon cancer is presented.

Case presentation

A 68-year-old Caucasian man underwent right hemicolectomy for invasive G2 adenocarcinoma. Two months later, endoscopy revealed a wide and well-functioning anastomosis with a hyperemic, hard, and thickened mucosal area of about 2 cm in diameter. Biopsies showed the presence of an adenocarcinoma with the same grading of the previous lesion. Ten days later, the patient underwent a new intervention; the last 10 cm of the ileum and half of the remaining transverse colon were resected, and the patient started adjuvant therapy. Specimen examination confirmed the presence of an adenocarcinoma (G2) penetrating the muscular layer of the wall; also, in this case, resection edges were free from tumoral invasion, and the removed lymph nodes were exempt from neoplastic colonization. The patient was seen in follow-up for about 5 years, and he did not show local or systemic manifestations.

Conclusions

Whenever a neoplastic recurrence on the anastomotic line occurs, in the presence of negative intestinal margins, as usual in right colectomies, the implantation of neoplastic cells could be the possible cause.

Stem Cell Marker Expression in Early Stage Colorectal Cancer is Associated with Recurrent Intestinal Neoplasia

BACKGROUND

Colorectal cancer (CRC) ranks second in cancer deaths worldwide and presents multiple management challenges, one of which is identifying high risk stage II disease that may benefit from adjuvant therapy. Molecular biomarkers, such as ones that identify stem cell activity, could better stratify high-risk cohorts for additional treatment.

METHODS

To identify possible biomarkers of high-risk disease in early-stage CRC, a discovery set (n = 66) of advanced-stage tumors were immunostained with antibodies to stemness proteins (CD166, CD44, CD26, and LGR5) and then digitally analyzed. Using a second validation cohort (n = 54) of primary CRC tumors, we analyzed protein and gene expression of CD166 across disease stages, and extended our analyses to CD166-associated genes (LGR5, ASCL2, BMI1, POSTN, and VIM) by qRT-PCR.

RESULTS

Stage III and metastatic CRC tumors highly expressed stem cell-associated proteins, CD166, CD44, and LGR5. When evaluated across stages, CD166 protein expression was elevated in advanced-stage compared to early-stage tumors. Notably, a small subset of stage I and II cancers harbored elevated CD166 protein expression, which correlated with development of recurrent cancer or adenomatous polyps. Gene expression analyses of CD166-associated molecules revealed elevated ASCL2 in primary tumors from patients who recurred.

CONCLUSIONS

We identified a protein signature prognostic of aggressive disease in early stage CRC. Stem cell-associated protein and gene expression identified a subset of early-stage tumors associated with cancer recurrence and/or subsequent adenoma formation. Signatures for stemness offer promising fingerprints for stratifying early-stage patients at high risk of recurrence.

Association between KRAS G13D mutations and anastomotic recurrence in colorectal cancer: Two case reports

RATIONALE

The prevalence of anastomotic recurrence (AR) in colorectal cancer (CRC) after resection of the primary tumor (PT) is 5% to 14%. However, no association has been observed between specific somatic genetic alterations and AR. Such associations may shed light on the mechanism of AR.

PATIENT CONCERNS

We experienced 2 patients with AR of CRC. The first patient was a 42-year-old woman who underwent resection of an AR of rectal cancer 2 times within 19 months after resection of the PT. The second patient was a 77-year-old woman who underwent resection of an AR of ascending colon cancer twice within 38 months after resection of the PT.

DIAGNOSIS

Both cases were diagnosed as repetitive AR.

INTERVENTIONS

Loss of heterozygosity analysis, microsatellite instability (MSI) study of 9 microsatellite loci, and mutational analysis of KRAS, BRAF, APC, TP53, and SMAD4 were performed.

OUTCOMES

All the lesions, except 1, harbored mutations in APC, KRAS, and TP53, without MSI, after neoadjuvant chemoradiotherapy. The APC, KRAS, and TP53 mutations were pathogenic or likely pathogenic in the PTs and ARs. Both women harbored the same KRAS G13D mutation, which accounts for 8% of all KRAS mutations in sporadic CRC s. The probability of the incidental occurrence of KRAS G13D mutations in both cases is 0.64%, provided that the mutations were independent of AR.

LESSONS

Our findings may shed light on the mechanism of AR in CRC, namely, that the PT harbored the same mutations as the AR and the lesions in both cases harbored the KRAS G13D mutation.

Local recurrences at the anastomotic area are clonally related to the primary tumor in sporadic colorectal carcinoma

PURPOSE

Anastomotic recurrences (AR) occur in 2-10% of colorectal carcinoma cases after resection of primary tumor (PT). Currently, there are no molecular data investigating their genetic profile and multiple theories exist about their pathogenesis. The aim of our study was to compare the genomic profile of AR to that of the patients' corresponding matched PT and, when available, to a distant metastasis (DM).

EXPERIMENTAL DESIGN

Thirty-six tumors from 14 patients were genotyped using a capture-based, next-generation assay to define the mutational status of 341 cancer-associated genes. All patients had R0 resection of their PT and AR occurred 1.1-7.0 years following PT resection. A DM or a second AR was analyzed in 8 patients. All tumors were microsatellite stable except in one patient with Lynch syndrome.

RESULTS

A total of 254 somatic mutations were detected including 138 mutations in the microsatellite stable (MSS) cases. The most commonly mutated genes were APC, KRAS, TP53, PIK3CA, ATM and PIK3R1. In all patients with MSS tumors the AR and PT shared between 50-100% of mutations, including mutations in key driver genes, consistent with these tumors being clonally related. Genetic events private to DM were not detected in AR and phylogenetic analysis showed that ARs were more closely related to PT than DM. In the Lynch syndrome patient the PT and AR showed distinct somatic mutations consistent with independent primaries.

CONCLUSIONS

ARs are clonally related to PT in sporadic colorectal carcinomas and do not appear to represent seeding of the anastomotic site by distant metastases.

Second isolated anastomotic recurrence after curative surgery for colorectal cancer

Introduction The two mechanisms postulated for cancer recurrence at the anastomosis site ('anastomotic recurrence' (AR)) after curative surgery for colorectal cancer are: (i) intraluminal dissemination of viable cancer cells; (ii) metachronous carcinogenesis related with changes in the local milieu provoked by the materials employed to carry out the anastomosis. Case History We describe a 79-year-old female who underwent a left hemicolectomy due to a stenotic lesion shown on colonoscopy: an adenocarcinoma (pT3NO, G2). One year after surgery, control colonoscopy revealed an AR, so a new resection was carried out. Pathology showed it to be a recurrent adenocarcinoma over the staple line (pT3N0, G2). One year after the second surgical procedure, control colonoscopy evinced a new AR, resulting in a new resection. Pathology revealed a new AR. Conclusions This is only the second time that a second isolated AR after curative resection for colorectal cancer has been reported.

Effect of immune suppression on metastasis in a patient with hepatocellular carcinoma metastasized to the colon and stomach: A case report

Hepatocellular carcinoma (HCC) is a highly malignant cancer, which can invade the portal vein and cause liver/long bone metastasis, although digestive tract metastatic tumor from the liver is very rare. This case report describes an unusual case of HCC (clear cell type), determined by pathology of the original liver tumor resected on March 16th, 2004. The patient returned to our hospital in February and July 2009 complaining of 'black stool' in the first instance, and 'anemia' on the second occasion. Colonoscopy and gastroscopy indicated colon cancer and stomach cancer, respectively. The right half colon and distal stomach were resected, and pathological inspection revealed liver cancer metastasis. The patient succumbed to respiratory failure due to liver cancer lung metastasis on the May 23rd, 2013. Tests for CD4⁺ and CD8⁺ T cells and the CD4⁺/CD8⁺ ratio, in addition to the expression of Fas, Fas ligand (FasL), indicated an evident difference in patient immunity during the tumor metastasis period. The disease progression in this patient suggested that immune surveillance may have been involved in the metastases. Furthermore, this case shows that clinicians should be alert to the possibility of metastases in uncommon sites that may be misdiagnosed as primary tumors. Surgical resection remains a valuable treatment for isolated digestive tract metastasis from liver cancer.

Effect of immune suppression on metastasis in a patient with hepatocellular carcinoma metastasized to the colon and stomach: A case report

Hepatocellular carcinoma (HCC) is a highly malignant cancer, which can invade the portal vein and cause liver/long bone metastasis, although digestive tract metastatic tumor from the liver is very rare. This case report describes an unusual case of HCC (clear cell type), determined by pathology of the original liver tumor resected on March 16th, 2004. The patient returned to our hospital in February and July 2009 complaining of 'black stool' in the first instance, and 'anemia' on the second occasion. Colonoscopy and gastroscopy indicated colon cancer and stomach cancer, respectively. The right half colon and distal stomach were resected, and pathological inspection revealed liver cancer metastasis. The patient succumbed to respiratory failure due to liver cancer lung metastasis on the May 23rd, 2013. Tests for CD4⁺ and CD8⁺ T cells and the CD4⁺/CD8⁺ ratio, in addition to the expression of Fas, Fas ligand (FasL), indicated an evident difference in patient immunity during the tumor metastasis period. The disease progression in this patient suggested that immune surveillance may have been involved in the metastases. Furthermore, this case shows that clinicians should be alert to the possibility of metastases in uncommon sites that may be misdiagnosed as primary tumors. Surgical resection remains a valuable treatment for isolated digestive tract metastasis from liver cancer.